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Abstract

Introduction: Reflection is a critical part of the learning cycle. Narrative medicine has been shown to help physicians-in-training develop both empathy and professional identity. A narrative medicine curriculum focused on the experience of the physician and challenging patient experiences creates opportunities in which to process complicated aspects of the experience of both patient and physician with other members of the training community. Methods: Fifteen 1-hour small-group reflective writing workshops comprise a 2-year narrative medicine curriculum. Each workshop uses selected literature to focus a discussion and a prompt for written reflection and can be integrated into a didactic curriculum. Teacher guides have been created to help untrained preceptors lead small-group sessions. Feedback forms are distributed to participating residents. Results: Out of 29 total residents enrolled at one program, 23 residents completed feedback forms, and 16 (69%) reported that the reflective writing sessions were relevant to their work as obstetrician-gynecologists. Residents stated the best parts of the course were reading and writing (n = 6; 27%), sharing writings with colleagues (n = 5; 21%), and having positive experiences with members of their community (n = 6; 27%). Some residents reported difficulty sharing their private reflections (n = 4; 17%). Discussion: A narrative medicine curriculum is a powerful tool for promoting reflection about the challenging work of training in obstetrics and gynecology and other specialties. Reflective writing workshops have been found to be acceptable to obstetrics and gynecology residents, and the curriculum has been successfully implemented at several training programs.

Keywords

Educational Objectives

Reflect on aspects of residency training that have created personal challenges and stresses.

Identify meaningful interactions with patients that have led to new insights.

Create reflective short writings in response to specific prompts.

Discuss reactions to literary works and personal reflections by colleagues in a safe and respectful manner.

Introduction

Residency training is a stressful experience for future physicians. Developing adaptive ways of processing the complex nature of the work is increasingly considered to be an essential component of residency training in order to avoid burnout.1,2 Burnout has been linked to poor outcomes for both physicians and their patients.3-6 It has been proposed that shutting down empathy is a protective response to the emotional labor required for bearing witness to suffering.7 However, engagement with the work may be protective against burnout and increase job satisfaction.6-7 Reflection has the potential to support personal awareness and positive professional identity and to foster resilience.4,8 This increased personal awareness may have the dual benefit of improving physician wellness and quality of care.7,9

Narrative medicine is an educational approach that uses art and literature to explore many dimensions of the complicated work of physicians by creating a space for and encouraging self-reflection. Narrative medicine has been found to positively impact empathy, resilience, and professional identity development.10,11 Implementing curricula that involve reflection is particularly challenging during residency training, when learners face conflicting demands for time. However, residency is a critical time for identity formation, and residents are at high risk for burnout.12,13

Obstetrics and gynecology is a field that presents practical and emotional hurdles for trainees. Long and physically demanding working hours mix with sensitive and difficult emotional content to provide a challenging clinical learning environment.14-16 There have been reports of successful integration of reflective curricula in obstetrics and gynecology training programs.17-19 The narrative medicine curriculum described in this report has been successfully implemented at five obstetrics and gynecology training programs.

Methods

The target audience is obstetrics and gynecology residents, PGY-1 through PGY-4.

Logistics
Small-group sessions include six to 10 participants and one to two facilitators. Facilitators do not need to have formal training in teaching writing or reading but should have some comfort with teaching small-group sessions. It may be helpful if at least one of the facilitators has familiarity with obstetrics and gynecology training.

Schedule
Fifteen 1-hour workshops are held over the course of a 2-year period, usually at intervals of 6-8 weeks between sessions. The workshops are held during regular didactic time. Each hour-long workshop includes in-class reading of the selection, a discussion of the workshop theme, and a reflective writing prompt. Included in the workshop descriptions are suggestions of texts used by the author. These should be considered as a guide, and facilitators could adapt any useful text to fit the needs of the session. The author has found it beneficial to use literature as opposed to news articles or other commentary because of the extra layers of meaning possible through close reading of carefully written poetry and prose. The curriculum theme and suggested readings are outlined in the following list:

Calling: Why Do You Do What You Do? “The Poet’s Obligation,” by Pablo Neruda.20

Work-Life Balance: “Bullet in the Brain,” by Tobias Wolff.21

Death and Dying: “The Death of Fred Clifton,” by Lucille Clifton.22

Abuse and Sexual Violence: “Power,” by Frank Huyler.23

Managing Expectations: “Girl,” by Jamaica Kincaid.24

Coping Mechanisms: “The Absolute Worst Thing,” by Seth Carey.25

Difference From Me: “Fat,” by Raymond Carver.26

Professionalism and Humility: “The Use of Force,” by William Carlos Williams.27

Pregnancy Loss: “Nesting in a Season of Light,” by Angela Wheelock.28

Sexuality and Erotica: “Physical Exam,” by David Watts.29

Self Care: “Hospital Haiku,” by Fran Bartkowski.30

Maintaining Hope: selection from Body of Work: Meditations on Mortality From the Human Anatomy Lab, by Christine Montross.31

Friendship and Boundaries: “The Death of Marilyn Monroe,” by Sharon Olds.32

Cultural Competencies: “War Dances,” by Sherman Alexie.33

Making Mistakes: “Incompatibility,” by Audrey Shafer.34

Workshop Structure
Each workshop follows the same general structure. A piece of literature such as a poem, short story, or selection from a larger work is read in class aloud by participants. Participants share reactions to the writing and discuss the topic of the workshop, guided by questions posed by the workshop leaders (see the teacher guides in Appendices A-O). Following this discussion, a writing prompt is conducted as outlined in the guides, and participants spend about 5-10 minutes writing creative and reflective pieces. Then, participants volunteer to read aloud from their writing and share thoughts about each other’s work.

Class Layout
Since participants will be reading and writing during the sessions, the optimal layout is to have participants seated around a large table. Audiovisual needs are minimal unless you choose media for the sessions that would require it. For some sessions, we have found it interesting to listen to audio recordings, especially for longer short stories. Another option would be to use visual artwork instead of literature, which would be more easily be shared with a projector.

Building a Narrative Medicine ProgramOver the 6 years that we have been doing this program, we have found that many faculty members and allied health professionals are interested in participating in the sessions as facilitators. A new user could discuss plans for a curriculum at a faculty meeting or education committee meeting to solicit volunteers. As the curriculum is designed to take place over several years, the time commitment is minimal aside from sitting in on the workshops every 1-2 months. At the programs where this curriculum has been introduced, the workshops have been taught by associate residency directors, teaching faculty, clinical educators, doulas, and other allied health professionals. Since the workshops can be taught with one or two facilitators, a newer facilitator can be paired with one more comfortable facilitating discussion sessions. Reaching out to the course designer for tips and resources may help as you launch the curriculum. If facilitators wish to reach out, please feel free to contact the author at abigail.winkel@nyumc.org.

Best Practices in Leading Narrative Medicine Workshops for Residents

Do not assign homework. Try to do all reading in class because residents find it hard to make time to do the reading ahead of time.

Publicize the workshop theme beforehand. Put on the schedule Narrative Medicine: Work-Life Balance, for example, and distribute the reading ahead of time if convenient. Some residents do prefer to read ahead of time and may want to mentally prepare prior to sessions on weightier topics.

Establish a safe space at the beginning of the sessions. Discourage residents from talking about the discussions and writings outside of the workshops.

Use the reading itself as an icebreaker. Sometimes, discussing the topic of the workshop broadly before reading can derail the discussion.

Read material aloud (or listen to audio recordings) at the start of class. Taking this time at the beginning of the sessions has the effect of centering participants and focusing them.

Workshop leaders should write and share their writings when appropriate. This models openness and yields insights that participants may appreciate.

Structure the workshops within routine scheduled didactic time. Even those residents naturally drawn to reading and writing are unlikely to do this work after hours.

Start on time, and end on time. Leave time to wrap up. Sometimes, the content of the workshops can be difficult, and residents appreciate the opportunity to pull themselves together before returning to clinical duties.

Occasionally, residents reveal significant difficulties during these sessions. Use these opportunities to refer those residents to professional help when needed.

The author has found that starting with the Cultural Competency or the Calling: Why Do You Do What You Do? workshop is an excellent way to open the curriculum with residents who are not familiar with this type of didactic activity.

Participation of faculty members as facilitators adds authenticity, but there may be some discomfort with involvement of program directors or other authority figures. Consider including junior faculty whom the residents are comfortable with.

Gather feedback on a regular basis, and make local changes that work for the residents in your program. Our feedback form (Appendix P), which has helped to refine the program over time, is included.

Results

During the past 6 years, we have done narrative medicine workshops with residents in obstetrics and gynecology, PGY-1 through PGY-4. This curriculum is in use at five obstetrics and gynecology residency training programs around the country. The workshops have been taught by a combination of obstetrics and gynecology faculty, as well as health educators, doulas, and teachers with master’s degrees in narrative medicine. In general, two teachers meet with approximately 10 residents for a 1-hour session. The sessions are scheduled during regular didactic time and are listed as mandatory teaching time for residents. Following the sessions, residents are asked to fill out the narrative medicine feedback form (Appendix P).

Out of 29 total residents enrolled at one program, 23 completed feedback forms, and 16 (69%) reported that the reflective writing sessions were relevant to their work as obstetrician-gynecologists. Six (27%) residents who completed the forms indicated that they enjoyed the reading and the writing, five (21%) indicated that they appreciated the chance to share and write with colleagues, and six (27%) felt that the course led to positive experiences with members of the community. Some residents (four; 17%) reported difficulty sharing their private reflections. When asked to elaborate on things they would change about the workshops, some residents suggested that meetings could be “optional or voluntary” or “less frequent with easier topics” and reported that “topics sometimes feel difficult to share.” Often, a small but vocal minority gave negative comments such as “I don’t see how this meets my needs better than a 1 hr massage.” While we feel that the sessions should not be voluntary, we have discussed within individual programs a mechanism allowing individual residents to ask to sit out one of the sessions. In this situation, it may be useful to give the teacher guide to the resident and ask him or her to complete the written reflection in private. However, we feel that a significant benefit of the curriculum is its impact on the community. Resident comments on the feedback form supported the idea that the workshops became “a place to laugh and share.” Other residents reported particularly appreciating the presence of their clinical faculty to reinforce the shared experience among obstetrician-gynecologists.

After each session, the workshop facilitators debriefed to address issues that arose during the sessions. These discussions centered on how the group dynamics evolved throughout the session, whether the majority of participants engaged in the discussion and sharing of writings, and whether they felt the reading and writing prompts successfully framed the discussion of the selected topic. Sometimes, these discussions resulted in changes to the teacher guides. For instance, certain sessions required icebreaker discussion points prior to diving into the reading. Other sessions were better served with two shorter writing prompts. The author felt that with some of the longer prose pieces, listening as a group to recordings of the stories being read aloud by authors and actors was an enjoyable and restful activity with which to start the session. These recordings may be available on the internet.

Discussion

When we first started doing narrative medicine with obstetrics and gynecology residents, we began with topics that focused on the physician experience (e.g., work-life balance, managing expectations, etc.) as well as a few particularly difficult topics related to clinical work (e.g., death and dying.)19 These original topics came from a nominal group process with 20 residents who identified and ranked topics that they felt were important to their life and work as obstetrician-gynecologists but were not adequately addressed in the traditional curriculum. Other topics have been added over time based on the interests of workshop leaders and residents and on the Council on Resident Education in Obstetrics and Gynecology Educational Objectives for residents.35

With time, it has become clear that the reflective writing workshop format is a useful way of addressing topics that do not readily come up during discussions about patients in the clinical environment and do not lend themselves to a didactic lecture format (e.g., pregnancy loss, sexual abuse and violence, etc.). The current 15-session curriculum is intended to take place over 2 years and repeat during the 4-year residency curriculum. While some sessions will repeat during each resident’s experience, we have found that once a few years have passed, residents bring different insights to the discussion. However, each program has implemented the curriculum slightly differently. Initially, some residents felt very challenged by this addition to the curriculum, but over time, the residents who have participated in the curriculum during their entire residency refer to ways that they have integrated reflective practice into their habits as a result of this curriculum.

During initial dissemination of the curriculum, it has been helpful for program champions to communicate with the curriculum author. We are very willing to work with future leaders of this type of curriculum to help roll it out in other programs. Getting feedback from the sessions in narrative format on the feedback forms is a helpful way to make changes. We have had some challenges with more sensitive material, and occasionally, the prompts touch a nerve with residents. If a resident has a difficult experience, it is useful to speak individually with him or her to figure out whether it is an issue with the curriculum or a personal difficulty for the resident. In general, we have found the introduction of this curriculum into our program provides a strong positive message about the value of physician wellness and engagement in the culture of the training program.

Author Information

Abigail
Ford
Winkel,
MD, FACOG:
Assistant Professor,
Department of Obstetrics and Gynecology,
New York University School of Medicine

Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451. http://dx.doi.org/10.1097/ACM.0000000000000134

Council on Resident Education in Obstetrics and Gynecology. Educational Objectives: Core Curriculum in Obstetrics and Gynecology. 10th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2013.